Racial disparities in cancer therapy: did the gap narrow between 1992 and 2002?

The Effect of Educational Intervention Based on PRECEDE Model on Promoting Skin Cancer Preventive Behaviors in High School Students

School-based education programs can be an effective way of educating adolescents about the dangers of exposure to sunlight and about preventive measures against this exposure and its relation to skin cancer. The aim of this study is to survey the effect of educational intervention based on the PRECEDE model on promoting skin cancer preventive behaviors in high school students of Fasa City, Fars Province, Iran. In this quasi-experimental study, 300 students (150 in experimental group and 150 in control group) in Fasa City, Fars Province, Iran, were selected in 2016-2017. The educational intervention for the experimental group consisted of six training sessions. A questionnaire consisting of demographic information, PRECEDE constructs (knowledge, attitude, self-efficacy, enabling factors, and social support), was used to measure skin cancer preventive behaviors before and 4 months after the intervention. Data were analyzed using SPSS 22 and paired t test, independent t test, and chi-square test at a significance level of p < 0.05. The mean age of the students was 16.05 ± 1.76 years in the experimental group and 16.20 ± 1.71 years in the control group. Four months after the intervention, the experimental group showed a significant increase in the knowledge, attitude, self-efficacy, enabling factors, social support, and skin cancer preventive behaviors compared to the control group. This study showed the effectiveness of the intervention based on the PRECEDE constructs in adoption of skin cancer preventive behaviors in 4 months post-intervention in students. Hence, this model can act as a framework for designing and implementing educational intervention for the prevention of skin cancer.

Appendiceal cancer masked as inflammatory appendicitis in the elderly, not an uncommon presentation (Surveillance Epidemiology and End Results (SEER)-Medicare Analysis)

BACKGROUND

The misdiagnosis of appendiceal cancer as inflammatory appendicitis is becoming of greater clinical concern because of the rise of nonoperative management especially in the elder population. To quantify this rate of misdiagnosis, we retrospectively reviewed SEER-Medicare data.

METHODS

The SEER-Medicare database was reviewed from 2000 to 2014. We identified patients older than 65 years old who were diagnosed with appendiceal cancer and then cross-referenced them for a diagnosis of inflammatory appendicitis. Demographic data and oncologic stage were collected.

RESULTS

Our results showed that 28.6% of appendiceal cancer patients received an incorrect initial diagnosis of inflammatory appendicitis. Patients older than 75 years of age were more likely to be misdiagnosed than those between ages 65 and 75 (risk ratio [RR]: 0.81; 95% confidence interval: 0.70-0.93; P = .003). We found that 42% of patients within the misdiagnosis group presented with an earlier stage of disease (stage 1 or 2) compared to 26% of those primarily diagnosed with appendiceal cancer (P < .001).

CONCLUSION

A significant proportion of patients older than 65 years old with appendiceal cancer were initially misdiagnosed with acute appendicitis. We suggest caution when considering a nonoperative approach for appendicitis in the elderly and follow-up imaging or an interval appendectomy should be part of the treatment plan.

The Association Between Out-of-Pocket Costs and Adherence to Adjuvant Endocrine Therapy Among Newly Diagnosed Breast Cancer Patients

OBJECTIVE

To determine how out-of-pocket costs for adjuvant endocrine therapy (AET) medication affects adherence among newly diagnosed breast cancer survivors with private health insurance who initiate therapy.

MATERIALS AND METHODS

We examined medical and pharmacy claims for the 1-year period after initiating AET using the Truven Health Analytics MarketScan database. Adherence was defined as ≥80% proportion of days covered. Mean out-of-pocket costs for AET fill were measured as the sum of copayments, coinsurance, and deductibles and adjusted to 30-day amounts. Using a multivariable logistic regression model we calculated adjusted risk ratios controlling for age, comorbidities, type of surgery, use of chemotherapy and/or radiation therapy, average out-of-pocket costs for other services, and pharmacy use characteristics.

RESULTS

Of the 6863 women 64 years and younger who were diagnosed with breast cancer and initiated AET, 73.9% were adherent (proportion of days covered≥80%). A total of 19% of patients had <$5 monthly out-of-pocket costs for AET, 30% had $5 to $9.99, 17% had $10 to $14.99, 10% had $15 to $19.99, and 25% had $20 or greater. Patients with out-of-pocket costs for AET between $10 and $14.99, $15 and $19.99, and >$20 were 6% to 8% less likely to be adherent compared with patients paying <$5.00, after controlling for covariates (P<0.05). Out-of-pocket costs for inpatient, outpatient, and other pharmacy services were not associated with adherence.

CONCLUSIONS

A substantial proportion of privately insured patients are nonadherent to AET and out-of-pocket costs for AET medication are significantly associated with a greater likelihood of nonadherence.

Disparities and Trends in Genetic Testing and Erlotinib Treatment among Metastatic Non-Small Cell Lung Cancer Patients

BACKGROUND

Despite reports of socioeconomic disparities in rates of genetic testing and targeted therapy treatment for metastatic non-small cell lung cancer (NSCLC), little is known about whether such disparities are changing over time.

METHODS

We performed a retrospective analysis to identify disparities and trends in genetic testing and treatment with erlotinib. Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we identified 9,900 patients with stage IV NSCLC diagnosed in 2007 to 2011 at age 65 or older. We performed logistic regression analyses to identify patient factors associated with odds of receiving a genetic test and erlotinib treatment, and to assess trends in these differences with respect to diagnosis year.

RESULTS

Patients were more likely to receive genetic testing if they were under age 75 at diagnosis [odds ratio (OR), 1.55] independent of comorbidity level, and this age-based gap showed a decrease over time (OR, 0.93). For untested patients, erlotinib treatment was associated with race (OR, 0.58, black vs. white; OR, 2.45, Asian vs. white), and was more likely among female patients (OR, 1.45); for tested patients, erlotinib treatment was less likely among low-income patients (OR, 0.32). Most of these associations persisted or increased in magnitude.

CONCLUSIONS

Race and sex are associated with rates of erlotinib treatment for patients who did not receive genetic testing, and low-income status is associated with treatment rates for those who did receive testing. The racial disparity remained stable over time, while the income-based disparity grew larger.

IMPACT

Attention to reducing disparities is needed as precision cancer treatments continue to be developed.

Socioeconomic Factors Associated with the Receipt of Contralateral Prophylactic Mastectomy in Women with Breast Cancer

Background: Contralateral prophylactic mastectomy (CPM) treatments have been on the rise among white women with early stage unilateral breast cancer who have a higher socioeconomic status (SES) and private insurance. Low income and uninsured women are not choosing CPM at the same rate. The purpose of this study was to evaluate the socioeconomic factors related to the choice of surgical treatment in women diagnosed with unilateral breast cancer in the state of New Jersey. Materials and Methods: This retrospective study of 10 years of breast cancer data abstracted from the New Jersey State Cancer Registry utilized bivariate analyses and two multivariate logistic regression models to analyze the effect of socioeconomics on choice of surgical treatment. Results: In New Jersey, 52,529 women were treated for breast cancer from 2004 to 2014. CPM rates increased gradually over time from 3.72% in 2004 to 10.82% in 2014 with women more likely to choose CPM if they were younger, white, and had private insurance (p < 0.001). The single factor that was most predictive of choosing CPM was access to immediate reconstruction (odds ratio 2.36, confidence interval 2.160-2.551). Women with low SES were much less likely to choose CPM. Conclusions: Results of this study may provide incentive for researchers to assess the impact of culture, race/ethnicity, and socioeconomics on a woman's interactions with health care providers so as to allow all women regardless of SES to express their needs, concerns, and wishes when confronted with a breast cancer diagnosis.

Prostate Cancer Disparity, Chemoprevention, and Treatment by Specific Medicinal Plants

Prostate cancer (PC) is one of the most common cancers in men. The global burden of this disease is rising. Its incidence and mortality rates are higher in African American (AA) men compared to white men and other ethnic groups. The treatment decisions for PC are based exclusively on histological architecture, prostate-specific antigen (PSA) levels, and local disease state. Despite advances in screening for and early detection of PC, a large percentage of men continue to be diagnosed with metastatic disease including about 20% of men affected with a high mortality rate within the African American population. As such, this population group may benefit from edible natural products that are safe with a low cost. Hence, the central goal of this article is to highlight PC disparity associated with nutritional factors and highlight chemo-preventive agents from medicinal plants that are more likely to reduce PC. To reach this central goal, we searched the PubMed Central database and the Google Scholar website for relevant papers. Our search results revealed that there are significant improvements in PC statistics among white men and other ethnic groups. However, its mortality rate remains significantly high among AA men. In addition, there are limited studies that have addressed the benefits of medicinal plants as chemo-preventive agents for PC treatment, especially among AA men. This review paper addresses this knowledge gap by discussing PC disparity associated with nutritional factors and highlighting the biomedical significance of three medicinal plants (curcumin, garlic, and Vernonia amygdalina) that show a great potential to prevent/treat PC, as well as to reduce its incidence/prevalence and mortality, improve survival rate, and reduce PC-related health disparity.

Factors Associated With Receipt of Radiation Therapy for Rectal Cancer

PURPOSE

Appropriate treatment for cancer is vital to increasing the likelihood of survival; however, for rectal cancer, there are demonstrated disparities in receipt of treatment by race/ethnicity and socioeconomic status. We evaluated factors associated with receipt of appropriate radiation therapy for rectal cancer using data from the Florida Cancer Data System that had been previously enriched with detailed treatment information collected from a Centers for Disease Control and Prevention Comparative Effectiveness Research study. This treatment information is not routinely available in cancer registry data and represents a unique data resource.

MATERIALS AND METHODS

Using multivariable regression, we evaluated factors associated with receiving radiation therapy among rectal cancer cases stage II/III. Our sample (n=403) included cases diagnosed in Florida in 2011 who were 18 years and older. Cases clinically staged as 0/I/IV were excluded.

RESULTS

Older age (odds ratio=0.96; 95% confidence interval, 0.94-0.97), the presence of one or more comorbidities (0.61; 0.39-0.96), and receipt of surgical intervention (0.44; 0.22-0.90) were associated with lack of radiation.

CONCLUSIONS

In this cohort of patients, sociodemographic factors such as race/ethnicity, insurance status, and socioeconomic status, did not influence the receipt of radiation. Further research is needed, however, to understand why aging, greater comorbidity, and having surgery present a barrier to radiation therapy, particularly given that it is a well-tolerated treatment in most patients.

Disparities in the Treatment and Outcome of Stage I Non-Small-Cell Lung Cancer in the 21st Century

BACKGROUND

African American (AA) individuals are less likely to receive treatment and more likely to die from cancer compared with Caucasian (C) individuals. Recent advancements in surgery and radiation have improved outcomes in early stage non-small-cell lung cancer (ESNSCLC). We studied racial disparities in ESNSCLC in the past decade.

PATIENTS AND METHODS

The Surveillance, Epidemiology, and End Results database was used to retrieve data of 62,312 ESNSCLC patients age 60 years and older diagnosed between 2004 and 2012. Patients were divided into racial cohorts: C, AA, American Indian (AI), Asian/Pacific Islander (API), or unknown. Demographics characteristics, therapy, and survival were compared using χ² test, Kaplan-Meier method, and Cox multivariate analysis.

RESULTS

AA and AI individuals were less likely to receive surgery than typical ESNSCLC patients (55.9% and 57.6% vs. 66.7%; P < .0001). Two-year overall survival (OS) for C individuals was 70%, for AA 65%, AI 60%, and API 76% (P < .0001). Two-year cancer-specific survival (CSS) for C individuals was 79%, AA 76%, AI 73%, and API 84% (P < .0001). Median CSS for AI and AA individuals was less than that of typical ESNSCLC patients (49 and 80 months vs. 107 months; P < .0001). This difference disappeared in multivariate analysis, accounted by sex, age, treatment, histology, and T stage (all P < .0001).

CONCLUSION

Despite treatment advancements in the past decade, AA and AI individuals continue to have worse OS and CSS from ESNSCLC. This might be because of the association with more adverse risk factors, including older age, squamous histology, male sex, T2 stage, and tendency to forgo treatment.

Contemporary prostate cancer radiation therapy in the United States: Patterns of care and compliance with quality measures

PURPOSE

Quality measures represent the standards of appropriate treatment agreed upon by experts in the field and often supported by data. The extent to which providers in the community adhere to quality measures in radiation therapy (RT) is unknown.

METHODS AND MATERIALS

The Comparative Effectiveness Analysis of Surgery and Radiation study enrolled men with clinically localized prostate cancer in 2011 and 2012. Patients completed surveys and medical records were reviewed. Patients were risk-stratified according to D'Amico classification criteria. Patterns of care and compliance with 8 quality measures as endorsed by national consortia as of 2011 were assessed.

RESULTS

Overall, 926 men underwent definitive RT (69% external beam radiation therapy [EBRT]), 17% brachytherapy (BT), and 14% combined EBRT and BT with considerable variation in radiation techniques across risk groups. Most men who received EBRT had dose-escalated EBRT (>75 Gy; 93%) delivered with conventional fractionation (<2 Gy; 95%), intensity modulated RT (76%), and image guided RT (85%). Most men treated with BT received I125 (77%). Overall, 73% of the men received EBRT that was compliant with the quality measures (dose-escalation, image-guidance, appropriate use of androgen deprivation therapy, and appropriate treatment target) but only 60% of men received BT that was compliant with quality measures (postimplant dosimetry and appropriate dose). African-American men (64%) and other minorities (62%) were less likely than white men (77%) to receive EBRT that was compliant with quality measures.

CONCLUSIONS

Most men who received RT for localized prostate cancer were treated with an appropriately high dose and received image guidance and intensity modulated RT. However, compliance with some nationally recognized quality measures was relatively low and varied by race. There are significant opportunities to improve the delivery of RT and especially for men of a minority race.

Exploring disparities in receipt of adjuvant chemotherapy in culturally and linguistically diverse groups: an Australian centre's experience

BACKGROUND

Globally, racial and ethnic disparities exist in treatments and outcomes for cancer patients. In Australia, there are few published data related to cancer patients from culturally and linguistically diverse (CALD) backgrounds.

AIM

To explore disparities in adjuvant chemotherapy utilisation in cancer patients from CALD groups.

METHODS

Retrospective analysis of patients who were recommended adjuvant chemotherapy for early stage breast cancer or early stage colorectal cancer between July 2011 and October 2014 was performed. Rates of adjuvant chemotherapy uptake were analysed between those who identified English as their first-preferred language, versus those who did not, as well as between patients who were born in a country where English is the main language (non-CALD), versus those born in a country where English is not the main language (CALD).

RESULTS

Two hundred and eleven patients were identified. One hundred and forty-three (67.7%) patients had early stage breast cancer and 68 (32.2%) patients had early stage colorectal cancer. No difference was detected in the acceptance of adjuvant chemotherapy between non-CALD (80.9%) and CALD patients (81.3%, P = 0.984) or between patients who identified English as their first-preferred language (80.8%) and those who did not (81.8%, P = 0.870). There was no difference in the rate of chemotherapy completion, with 75.6% completion in the non-English-speaking group and 81.1% in the English-speaking group (P = 0.426).

CONCLUSION

No difference was observed in adjuvant chemotherapy utilisation in patients who identified English as their first-preferred language compared to those who did not, as well as between non-CALD and CALD groups. This is the first study to assess these differences in Australia.

Racial Disparities in the Presentation and Treatment of Colorectal Cancer: A Statewide Cross-sectional Study

BACKGROUND

Non-Hispanic blacks (NHB) and Hispanics often present with advanced colorectal cancer (CRC). The aim of the study was to characterize CRC differences among Hispanics, NHB, and non-Hispanic whites (NHW).

METHODS

A cross-sectional analysis and logistic regression of 2009 Florida Agency for Healthcare Administration Hospital Admission Database data for CRC using the International Classification of Diseases, 9th Revision, Clinical Modification codes was performed. Outcomes included CRC location, frequency of metastasis and colectomy rates. Each minority group was compared with NHW.

RESULTS

A total of 34,577 patients were NHW, 5190 were NHB, and 5033 were Hispanic. NHB had more proximal CRC [odds ratio (OR), 1.17; 95% confidence interval (CI), 1.09-1.25; P<0.0001]; Hispanics had more distal CRC (OR, 0.90; 95% CI, 0.83-0.96; P=0.0024). Hispanics had increased metastases (OR, 1.11; 95% CI, 1.02-1.22; P=0.04). NHB and Hispanics underwent fewer colectomies [(OR, 0.93; 95% CI, 0.86-0.99; P=0.03) and (OR, 0.9; 95% CI, 0.84-0.97; P=0.001), respectively].

CONCLUSIONS

Disparities in CRC metastases and colectomy rates exist among these racial groups in Florida. This work should serve as a foundation to study potential causes and to design culture-specific interventions.

Disparities in the Use of Programmed Death 1 Immune Checkpoint Inhibitors

Amid growing excitement for immune checkpoint inhibitors of programmed death protein 1 (anti-PD1 agents), little is known about whether race- or sex-based disparities exist in their use. In this observational study, we constructed a large and mostly community-based cohort of patients with advanced stage cancers, including melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma, to compare the odds of receiving systemic treatment with or without anti-PD1 agents by race and by sex. In multivariable models that adjusted for age, stage, and number of prior anticancer therapies, we found no significant race-based disparities in anti-PD1 treatment. However, among patients with NSCLC, males had significantly higher odds of receiving anti-PD1 treatment compared with females (odds ratio 1.13, 95% confidence interval 1.02-1.24, p = .02). This finding suggests that as anti-PD1 agents enter the market to transform patient care, it will be critical to monitor for disparities in the use of these drugs.

Disparities by race, age, and sex in the improvement of survival for lymphoma: Findings from a population-based study

Objective

To evaluate improvement in survival of lymphoma patients from 1990 to 2014, stratified by age, sex and race using Surveillance Epidemiology and End-Result Survey Program (SEER) data.

Study design and setting

We identified 113,788 incident lymphoma cases from nine SEER cancer registries were followed up for cause-specific mortality from lymphoma. Cox proportional hazard regression was used to estimate hazard ratios (HRs) and their respective 95% confidence interval (CIs) for various time periods within groups stratified by race, age and sex.

Results

Five-year survival for Hodgkin’s lymphoma (HL) was 89% for patients 20–49 years of age. For this age group, compared to 1990–1994, survival significantly improved in 2000–2004 (HR = 0.65; 95% CI: 0.54–0.78), 2005–2009 (HR = 0.46, 95% CI: 0.38–0.57) and 2010–2014 (HR = 0.29, 95% CI: 0.20–0.41). Hodgkin’s lymphoma patients aged 75–85 years had 5-year survival of 37% and in these patients, compared to 1990-1994, survival only improved from 2005 onward (HR = 0.67, 95% CI: 0.50–0.90). In patients with non-Hodgkin’s Lymphoma (NHL), all age groups showed survival improvements between 1990–1994 period and 2010–2014 period. Improvements in HL and NHL survival were seen for all race categories and both genders.

Conclusion

Survival among US lymphoma patients has improved substantially between 1990–1994 period and 2010–2014 period, though disease-specific mortality was still higher in older age groups.

Racial disparities in guideline-concordant cancer care and mortality in the United States

Purpose

We identified the frequency of racial disparities in guideline-concordant cancer care for select common disease sites in the United States and the impact of guideline concordance on mortality disparities.

Methods and materials

Using Surveillance, Epidemiology, and End Results Medicare data, we evaluated patients age >65 years of black or non-Hispanic white race who were diagnosed with stage III breast (n = 3607), stage I (n = 14,605) or III (n = 15,609) non-small cell lung, or stage III prostate (n = 3548) cancer between 2006 and 2011. Chemotherapy, surgery, and radiation therapy (RT) treatments were identified using claims data. Pearson χ² was used to test the associations between race and guideline concordance on the basis of National Comprehensive Cancer Network curative treatment guidelines. Mortality risks were modeled using Cox proportional hazards.

Results

Black patients were less likely to receive guideline-concordant curative treatment than non-Hispanic white patients for stage III breast cancer postmastectomy RT (53% black, 61% white; P = .0014), stage I non-small cell lung cancer stereotactic radiation or surgery (61% black, 75% white; P < .0001), stage III non-small cell lung cancer chemotherapy in addition to RT or surgery (36% black, 41% white; P = .0001), and stage III prostate cancer RT or prostatectomy (82% black, 95% white; P < .0001). Disparities in guideline concordance impacted racial mortality disparities. Specifically, hazard ratios that demonstrated elevated all-cause mortality risks in black patients were lowered (and more closely approached hazard ratio of 1.00) after adjusting for guideline concordance. A similar impact for cause-specific mortality was observed.

Conclusions

Racial disparities in the receipt of curative cancer therapy impacted racial mortality disparities across multiple cancer sites. Benchmarking adherence to guideline-concordant care could represent an opportunity to stimulate improvements in disparities in cancer treatment and survival.

Race is an independent predictor of survival in patients with soft tissue sarcoma of the extremities

BACKGROUND

In the United States, race and socioeconomic status are well known predictors of adverse outcomes in several different cancers. Existing evidence suggests that race and socioeconomic status may impact survival in soft tissue sarcoma (STS). We investigated the National Cancer Database (NCDB), which contains several socioeconomic and medical variables and contains the largest sarcoma patient registry to date. Our goal was to determine the impact of race, ethnicity and socioeconomic status on patient survival in patients with soft tissue sarcoma of the extremities (STS-E).

METHODS

We retrospectively analyzed 14,067 STS-E patients in the NCDB from 1998 through 2012. Patients were stratified based on race, ethnicity and socioeconomic status. Univariate and multivariate analyses were used to correlate specific outcomes and survival measures with these factors. Then, long-term survival between groups was evaluated using the Kaplan-Meier (KM) method with comparisons based on the log-rank test. Multiple variables were analyzed between two groups.

RESULTS

Of the 14,067 patients analyzed, 84.9% were white, 11% were black and 4.1% were Asian. Black patients were significantly more likely (7.18% vs 5.65% vs 4.47%) than white or Asian patients to receive amputation (p = 0.027). Black patients were also less likely to have either an above-median education level or an above-median income level (p < 0.001). In addition, black patients were more likely to be uninsured (p < 0.001) and more likely to have a higher Charleson Comorbidity Score than white or Asian patients. Tumors were larger in size upon presentation in black patients than in white or Asian patients (p < 0.001). Black patients had significantly poorer overall survival than did white or Asian patients (p < 0.001) with a KM 5-year survival of 61.4% vs 66.9% and 69.9% respectively, and a 24% higher independent likelihood of dying in a multivariate analysis.

CONCLUSION

This large database review reveals concerning trends in black patients with STS-E. These include larger tumors, poorer resources, a greater likelihood of amputation, and poorer survival than white and Asian patients. Future studies are warranted to help ensure adequate access to effective treatment for all patients.

Underutilization and disparities in access to EGFR testing among Medicare patients with lung cancer from 2010 - 2013

Background

Tumor testing for mutations in the epidermal growth factor receptor (EGFR) gene is indicated for all newly diagnosed, metastatic lung cancer patients, who may be candidates for first-line treatment with an EGFR tyrosine kinase inhibitor. Few studies have analyzed population-level testing.

Methods

We identified clinical, demographic, and regional predictors of EGFR & KRAS testing among Medicare beneficiaries with a new diagnosis of lung cancer in 2011–2013 claims. The outcome variable was whether the patient underwent molecular, EGFR and KRAS testing. Independent variables included: patient demographics, Medicaid status, clinical characteristics, and region where the patient lived. We performed multivariate logistic regression to identify factors that predicted testing.

Results

From 2011 to 2013, there was a 19.7% increase in the rate of EGFR testing. Patient zip code had the greatest impact on odds to undergo testing; for example, patients who lived in the Boston, Massachusetts hospital referral region were the most likely to be tested (odds ratio (OR) of 4.94, with a 95% confidence interval (CI) of 1.67–14.62). Patient demographics also impacted odds to be tested. Asian/Pacific Islanders were most likely to be tested (OR 1.63, CI 1.53–1.79). Minorities and Medicaid patients were less likely to be tested. Medicaid recipients had an OR of 0.74 (CI 0.72–0.77). Hispanics and Blacks were also less likely to be tested (OR 0.97, CI 0.78–0.99 and 0.95, CI 0.92–0.99), respectively. Clinical procedures were also correlated with testing. Patients who underwent transcatheter biopsies were 2.54 times more likely to be tested (CI 2.49–2.60) than those who did not undergo this type of biopsy.

Conclusions

Despite an overall increase in EGFR testing, there is widespread underutilization of guideline-recommended testing. We observed racial, income, and regional disparities in testing. Precision medicine has increased the complexity of cancer diagnosis and treatment. Targeted interventions and clinical decision support tools are needed to ensure that all patients are benefitting from advances in precision medicine. Without such interventions, precision medicine may exacerbate racial disparities in cancer care and health outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4190-3) contains supplementary material, which is available to authorized users.

Implementation of hypofractionated prostate radiation therapy in the United States: A National Cancer Database analysis

PURPOSE

Preclinical and clinical research over the past several decades suggests that hypofractionated (HFxn) radiation therapy schedules produce similar treatment outcomes compared with conventionally fractionated (CFxn) radiation therapy for definitive treatment of localized prostate cancer (PCa). We sought to evaluate national trends and identify factors associated with HFxn utilization using the US National Cancer Database.

METHODS AND MATERIALS

We queried the National Cancer Database for men diagnosed with localized (N0,M0) PCa from 2004 through 2013 treated with external beam radiation therapy. Patients were grouped by dose per fraction (DpF) in Gray: CFxn was defined as DpF ≤2.0, moderate HFxn as DpF >2.0 but <5.0, and extreme HFxn as DpF ≥5.0. Men receiving DpF <1.5 or >15.0 were excluded, as were those receiving <25 or >90 Gy total dose. Multiple logistic regression was performed to identify demographic, clinical, and treatment factor associations.

RESULTS

A total of 132,403 men were identified, with 120,055 receiving CFxn, 7264 moderate HFxn, and 5084 extreme HFxn. Although CFxn was by far the most common approach over the analysis period, HFxn use increased from 6.2% in 2004 to 14.2% in 2013 (P < .01). Extreme HFxn use increased the most (from 0.3% to 8.5%), whereas moderate HFxn utilization was unchanged (from 5.9% to 5.7%). HFxn use was independently associated with younger age, later year of diagnosis, non-black race, non-Medicaid insurance, non-Western residence, higher income, academic treatment facility, greater distance from treatment facility, low-risk disease group (by National Comprehensive Cancer Network criteria), and nonreceipt of hormone therapy.

CONCLUSIONS

Although CFxn remains the most common radiation therapy schedule for localized PCa, use of HFxn appears to be increasing in the United States as a result of increased extreme HFxn use. Financial and logistical factors may accelerate adoption of shorter schedules. Considering the multiple demographic and prognostic differences identified between these groups, randomized outcome data comparing extreme HFxn to alternatives are desirable.

Trend in Age and Racial Disparities in the Receipt of Postlumpectomy Radiation Therapy for Stage I Breast Cancer: 2004-2009

OBJECTIVES

Significant effort has been expended over the past decade to reduce racial disparities in breast cancer care. Whether disparities in receipt of appropriate radiotherapy care for breast cancer persisted despite these efforts is unknown, as is the impact of being eligible for Medicare. We therefore investigated trends in racial differences by age in postbreast lumpectomy radiation therapy (PLRT) from 2004 to 2009.

MATERIALS AND METHODS

We analyzed the Surveillance, Epidemiology and End Results registry database for women aged 40 to 85 years who underwent lumpectomy for stage I breast cancer and were eligible for PLRT. We examined variables potentially associated with the receipt of PLRT, including year of diagnosis, race, and examined women separately by age group.

RESULTS

Among 67,124 women aged 40 to 85 years undergoing lumpectomy, receipt of PLRT decreased from 80.7% in 2004 to 76.8% by 2009 (P<0.001). There remained a persistent disparity in PLRT among African American women (in 2004, 80.6% white vs. 78.9% African American and in 2009, 77.5% white vs. 72.0% African American). In multivariable logistic regression, African American race (odds ratio [OR], 0.82; 95% confidence interval [CI]. 0.76-0.89) and being diagnosed more recently were associated with lower odds of PLRT (OR for 2009 vs. 2004: 0.74; 95% CI, 0.69-0.79), whereas older women typically covered by public health insurance (aged 65 to 69 y) were more likely to receive PLRT (OR, 1.09; 95% CI, 1.02-1.15).

CONCLUSIONS

PLRT decreased by a significant percentage of 3.9% among all women in recent years, and racial disparities in PLRT receipt have persisted. Medicare eligibility increased the likelihood of PLRT receipt.

Risk of Death from Prostate Cancer with and without Definitive Local Therapy when Gleason Pattern 5 is Present: A Surveillance, Epidemiology, and End Results Analysis

Purpose The purpose is to evaluate the patterns of care and comparative effectiveness for cause-specific and overall survival of definitive local treatments versus conservatively managed men with a primary or secondary Gleason pattern of 5. Methods and materials Patients diagnosed from 2004 to 2012 with a primary or secondary Gleason pattern of 5 N0M0 prostate cancer were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan-Meier and Cox regression analyses were used to estimate the survival. Results We identified 20,560 men. Median age and follow-up were 68 years and 4.33 years, respectively. At eight years, cause-specific survival (CSS) was 86.6% and 57.4% of those receiving and not receiving definitive local treatments, respectively. For CSS multivariate analysis, the following were significant: age, race, insurance status, total Gleason Score, T-stage, and type or omission of definitive local treatments. Compared to prostatectomy alone, men not undergoing definitive local treatments had the highest risk of death (HR: 6.07; 95% CI: 5.19-7.10). Those undergoing external beam radiotherapy alone (HR: 2.11; 95% CI: 1.80-2.48) were also at elevated risk of death. The number needed to treat (NNT) to prevent a prostate cancer death at eight years was three persons. Conclusions Death from prostate cancer with a primary or secondary Gleason pattern of 5 histology without definitive local treatment is high. In this hypothesis-generating study, we found that men with a limited life expectancy (less than eight years) and non-metastatic Gleason pattern of 5 disease may benefit from definitive local treatments. Given the high mortality in men with a Gleason pattern of 5, combined modality local therapies and consideration of chemotherapies may be warranted.

Colorectal cancer statistics, 2017

Colorectal cancer (CRC) is one of the most common malignancies in the United States. Every 3 years, the American Cancer Society provides an update of CRC incidence, survival, and mortality rates and trends. Incidence data through 2013 were provided by the Surveillance, Epidemiology, and End Results program, the National Program of Cancer Registries, and the North American Association of Central Cancer Registries. Mortality data through 2014 were provided by the National Center for Health Statistics. CRC incidence rates are highest in Alaska Natives and blacks and lowest in Asian/Pacific Islanders, and they are 30% to 40% higher in men than in women. Recent temporal patterns are generally similar by race and sex, but differ by age. Between 2000 and 2013, incidence rates in adults aged ≥50 years declined by 32%, with the drop largest for distal tumors in people aged ≥65 years (incidence rate ratio [IRR], 0.50; 95% confidence interval [95% CI], 0.48-0.52) and smallest for rectal tumors in ages 50 to 64 years (male IRR, 0.91; 95% CI, 0.85-0.96; female IRR, 1.00; 95% CI, 0.93-1.08). Overall CRC incidence in individuals ages ≥50 years declined from 2009 to 2013 in every state except Arkansas, with the decrease exceeding 5% annually in 7 states; however, rectal tumor incidence in those ages 50 to 64 years was stable in most states. Among adults aged <50 years, CRC incidence rates increased by 22% from 2000 to 2013, driven solely by tumors in the distal colon (IRR, 1.24; 95% CI, 1.13-1.35) and rectum (IRR, 1.22; 95% CI, 1.13-1.31). Similar to incidence patterns, CRC death rates decreased by 34% among individuals aged ≥50 years during 2000 through 2014, but increased by 13% in those aged <50 years. Progress against CRC can be accelerated by increasing initiation of screening at age 50 years (average risk) or earlier (eg, family history of CRC/advanced adenomas) and eliminating disparities in high-quality treatment. In addition, research is needed to elucidate causes for increasing CRC in young adults. CA Cancer J Clin 2017. © 2017 American Cancer Society. CA Cancer J Clin 2017;67:177-193. © 2017 American Cancer Society.

Factors Associated with Adherence to Adjuvant Endocrine Therapy Among Privately Insured and Newly Diagnosed Breast Cancer Patients: A Quantile Regression Analysis

BACKGROUND

Adherence to adjuvant endocrine therapy (AET) for estrogen receptor-positive breast cancer remains suboptimal, which suggests that women are not getting the full benefit of the treatment to reduce breast cancer recurrence and mortality. The majority of studies on adherence to AET focus on identifying factors among those women at the highest levels of adherence and provide little insight on factors that influence medication use across the distribution of adherence.

OBJECTIVE

To understand how factors influence adherence among women across low and high levels of adherence.

METHODS

A retrospective evaluation was conducted using the Truven Health MarketScan Commercial Claims and Encounters Database from 2007-2011. Privately insured women aged 18-64 years who were recently diagnosed and treated for breast cancer and who initiated AET within 12 months of primary treatment were assessed. Adherence was measured as the proportion of days covered (PDC) over a 12-month period. Simultaneous multivariable quantile regression was used to assess the association between treatment and demographic factors, use of mail order pharmacies, medication switching, and out-of-pocket costs and adherence. The effect of each variable was examined at the 40th, 60th, 80th, and 95th quantiles.

RESULTS

Among the 6,863 women in the cohort, mail order pharmacies had the greatest influence on adherence at the 40th quantile, associated with a 29.6% (95% CI = 22.2-37.0) higher PDC compared with retail pharmacies. Out-of-pocket cost for a 30-day supply of AET greater than $20 was associated with an 8.6% (95% CI = 2.8-14.4) lower PDC versus $0-$9.99. The main factors that influenced adherence at the 95th quantile were mail order pharmacies, associated with a 4.4% higher PDC (95% CI = 3.8-5.0) versus retail pharmacies, and switching AET medication 2 or more times, associated with a 5.6% lower PDC versus not switching (95% CI = 2.3-9.0).

CONCLUSIONS

Factors associated with adherence differed across quantiles. Addressing the use of mail order pharmacies and out-of-pocket costs for AET may have the greatest influence on improving adherence among those women with low adherence.

DISCLOSURES

This research was supported by a Ruth L. Kirschstein National Research Service Award for Individual Predoctoral Fellowship grant from the National Cancer Institute (grant number F31 CA174338), which was awarded to Farias. Additionally, Farias was funded by a Postdoctoral Fellowship at the University of Texas School of Public Health Cancer Education and Career Development Program through the National Cancer Institute (NIH Grant R25 CA57712). The other authors declare no conflicts of interest.

DISCLAIMER

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health. Farias was primarily responsible for the study concept and design, along with Hansen and Zeliadt and with assistance from the other authors. Farias, Hansen, and Zeliadt took the lead in data interpretation, assisted by the other authors. The manuscript was written by Farias, along with Thompson and assisted by the other authors, and was revised by Ornelas, Li, and Farias, with assistance from the other authors.

White-Black Differences in Cancer Incidence, Stage at Diagnosis, and Survival Among Older Adults

OBJECTIVE

To identify potential White-Black differences in cancer incidence rates, stage at diagnosis, and relative survival probabilities among older adults using Surveillance, Epidemiology, and End Results (SEER) data.

METHOD

Differences in cancer incidence, stage at diagnosis, and 5-year relative survival probability were examined for cases diagnosed within the most recent 5-year period and over time for cases diagnosed from 1973 to 2013 (incidence only) for older White and Black adults.

RESULTS

Among adults aged 65 to 74, 75 to 84, and 85 years and older, Black adults had higher cancer incidence rates per 100,000 than White males from 1973 to 2013, respectively. Late stage and unstaged cancers were more common among Black adults in each of the three age groups compared with Whites. Five-year relative survival probability for all invasive cancers combined was higher for Whites than Blacks in each of the three age groups.

DISCUSSION

Continued efforts are needed to reduce racial disparities in cancer incidence and mortality among older adults.

Sociodemographic Disparities in Cure-Intended Treatment in Localized Prostate Cancer

PURPOSE

Disparities in prostate cancer (PCa) morbidity and mortality occur across various populations. We investigated the sociodemographic correlates of treatment and disparities in the application of cure-intended (i.e., radical prostatectomy [RP], radiation therapy [RT]) treatment strategies in localized PCa among Texas residents diagnosed with PCa.

METHODS

We analyzed data from the Texas Cancer Registry on men diagnosed with stage T1 or T2 PCa between 2004 and 2009. Multinomial logistic regression analysis was used to explore independent associations between cure-intended treatment modalities and sociodemographic characteristics (age, race/ethnicity, socioeconomic status [SES], and geographic location (rural versus urban)) using patients who did not receive definitive treatment as comparison group.

RESULTS

Of 46,971 patients with available treatment data, age-adjusted treatment rates were 39.1% RP, 30.7% RT, and 30.2% for all other non-curative modalities. Compared to patients under 60 years, those ≥60 were less likely to receive RP, patients between 60 and 80 years were more likely to undergo RT, while those 80 years or older were less likely. Non-Hispanic blacks (OR =0.55, 95% CI, 0.50-0.59) and Hispanics (OR = 0.68, 95%CI, 0.62-0.74) were less likely to receive RP compared with whites. Hispanics were significantly less likely to receive RT (OR = 0.78, 95%CI, 0.72-0.85) than blacks and whites. People of low SES were 35% (OR = 0.65, 95%CI, 0.60-0.69) and 15% (OR = 0.85, 95%CI, 0.79-0.90) less likely to receive RP and RT, respectively, compared with those of high SES. Rural-urban status was not associated with cure-intended treatment.

CONCLUSION

Potential sociodemographic disparities exist in the application of cure-intended treatment in localized prostate cancer in Texas particularly in race/ethnicity and SES.

Insurance Status and Racial Disparities in Cancer-Specific Mortality in the United States: A Population-Based Analysis

Background: Cancer-specific mortality (CSM) is known to be higher among blacks and lower among Hispanics compared with whites. Private insurance confers CSM benefit, but few studies have examined the relationship between insurance status and racial disparities. We sought to determine differences in CSM between races within insurance subgroups.Methods: A population-based cohort of 577,716 patients age 18 to 64 years diagnosed with one of the 10 solid malignancies causing the greatest mortality over 2007 to 2012 were obtained from Surveillance, Epidemiology, and End Results. A Cox proportional hazards model for CSM was constructed to adjust for known prognostic factors, and interaction analysis between race and insurance was performed to generate stratum-specific HRs.Results: Blacks had similar CSM to whites among the uninsured [HR = 1.01; 95% confidence interval (CI), 0.96-1.05], but higher CSM among the Medicaid (HR = 1.04; 95% CI, 0.01-1.07) and non-Medicaid (HR = 1.14; 95% CI, 1.12-1.16) strata. Hispanics had lower CSM compared with whites among uninsured (HR = 0.80; 95% CI, 0.76-0.85) and Medicaid (HR = 0.88; 95% CI, 0.85-0.91) patients, but there was no difference among non-Medicaid patients (HR = 0.99; 95% CI, 0.97-1.01). Asians had lower CSM compared with whites among all insurance types: uninsured (HR = 0.80; 95% CI, 0.76-0.85), Medicaid (HR = 0.81; 95% CI, 0.77-0.85), and non-Medicaid (HR = 0.85; 95% CI, 0.83-0.87).Conclusions: The disparity between blacks and whites was largest, and the advantage of Hispanic race was absent within the non-Medicaid subgroup.Impact: These findings suggest that whites derive greater benefit from private insurance than blacks and Hispanics. Further research is necessary to determine why this differential exists and how disparities can be improved. Cancer Epidemiol Biomarkers Prev; 26(6); 869-75. ©2017 AACR.

The Effects of Hospital Characteristics on Delays in Breast Cancer Diagnosis in Appalachian Communities: A Population-Based Study

PURPOSE

Despite being generally accepted that delays in diagnosing breast cancer are of prognostic and psychological concern, the influence of hospital characteristics on such delays remains poorly understood, especially in rural and underserved areas. However, hospital characteristics have been tied to greater efficiency and warrant further investigation as they may have implications for breast cancer care in these areas.

METHODS

Study data were derived from the Kentucky, North Carolina, Ohio, and Pennsylvania state central cancer registries (2006-2008). We then linked Medicare enrollment files and claims data (2005-2009), the Area Resource File (2006-2008), and the American Hospital Association Annual Survey of Hospitals (2007) to create an integrated data set. Hierarchical linear modeling was used to regress the natural log of breast cancer diagnosis delay on a number of hospital-level, demographic, and clinical characteristics.

FINDINGS

The baseline study sample consisted of 4,547 breast cancer patients enrolled in Medicare that lived in Appalachian counties at the time of diagnosis. We found that hospitals with for-profit ownership (P < .01) had shorter diagnosis delays than their counterparts. Estimates for comprehensive oncology services, system membership and size were not statistically significant at conventional levels.

CONCLUSIONS

Some structural characteristics of hospitals (eg, for-profit ownership) in the Appalachian region are associated with having shorter delays in diagnosing breast cancer. Researchers and practitioners must go beyond examining patient-level demographic and tumor characteristics to better understand the drivers of timely cancer diagnosis, especially in rural and underserved areas.

Racial and Socioeconomic Treatment Disparities in Adolescents and Young Adults with Stage II-III Rectal Cancer

INTRODUCTION

Stage II-III rectal cancer requires multidisciplinary cancer care, and adolescents and young adults (AYA, ages 15-39 years) often do not receive optimal cancer therapy.

METHODS

Overall, 3295 AYAs with clinical stage II-III rectal cancer were identified in the National Cancer Database. Factors associated with the receipt of adjuvant and surgical therapies, as well as overall survival (OS), were examined.

RESULTS

The majority of patients were non-Hispanic White (72.0 %), male (57.5 %), and without comorbidities (93.8 %). A greater proportion of Black and Hispanic patients did not receive radiation (24.5 and 27.1 %, respectively, vs. 16.5 % for non-Hispanic White patients), surgery (22.4 % and 21.6 vs. 12.3 %), or chemotherapy (21.5 % and 24.1 vs. 14.7 %) compared with non-Hispanic White patients (all p < 0.05). After controlling for competing factors, Black (odds ratio [OR] 0.7, 95 % confidence interval [CI] 0.5-0.9) and Hispanic patients (OR 0.6, 95 % CI 0.4-0.9) were less likely to receive neoadjuvant chemoradiation compared with non-Hispanic White patients. Females, the uninsured, and those treated at a community cancer center were also less likely to receive neoadjuvant therapy. Having government insurance (OR 0.22, 95 % CI 010-0.49) was a predictor for not receiving surgery. Although 5-year OS was lower (p < 0.05) in Black (59.8 %) and Hispanic patients (65.9 %) compared with non-Hispanic White patients (74.9 %), on multivariate analysis race did not impact mortality. Not having surgery (hazard ratio [HR] 7.1, 95 % CI 2.8-18.2) had the greatest influence on mortality, followed by poorly differentiated histology (HR 3.0, 95 % CI 1.3-6.5), nodal positivity (HR 2.6, 95 % CI 1.9-3.6), no chemotherapy (HR 1.9, 95 % CI 1.03-3.6), no insurance (HR 1.7, 95 % CI 1.1-2.7), and male sex (HR 1.5, 95 % CI 1.1-2.0).

CONCLUSION

There are racial and socioeconomic disparities in the treatment of stage II-III rectal cancer in AYAs, many of which impact OS. Interventions that can address and mitigate these differences may lead to improvements in OS for some patients.

Race/ethnicity and socio-economic differences in colorectal cancer surgery outcomes: analysis of the nationwide inpatient sample

Background

The purpose of this study was to examine racial and socio-economic differences in the receipt of laparoscopic or open surgery among patients with colorectal cancer, and to determine if racial and socio-economic differences exist in post-surgical complications, in-hospital mortality and hospital length of stay among patients who received surgery.

Methods

We conducted a cross-sectional analysis of hospitalized patients with a primary diagnosis of colorectal cancer between 2007 and 2011 using data from Nationwide Inpatient Sample. ICD-9 codes were used to capture primary diagnosis, surgical procedures, and health outcomes during hospitalization. We used logistic regression analysis to determine racial and socio-economic predictors of surgery type, post-surgical complications and mortality, and linear regression analysis to assess hospital length of stay.

Results

A total of 122,631 patients were admitted with a primary diagnosis of malignant colorectal cancer between 2007 and 2011. Of these, 17,327 (14.13 %) had laparoscopic surgery, 70,328 (57.35 %) received open surgery, while 34976 (28.52 %) did not receive any surgery. Black (36 %) and Hispanic (34 %) patients were more likely to receive no surgery compared with Whites (27 %) patients. However, among patients that received any surgery, there were no racial differences in which surgery was received (laparoscopic versus open, p = 0.2122), although socio-economic differences remained, with patients from lower residential income areas significantly less likely to receive laparoscopic surgery compared with patients from higher residential income areas (OR: 0.74, 95 % CI: 0.70-0.78). Among patients who received any surgery, Black patients (OR = 1.07, 95 % CI: 1.01-1.13), and patients with Medicare (OR = 1.16, 95 % CI: 1.11-1.22) and Medicaid (OR = 1.15, 95 % CI: 1.07-1.25) insurance experienced significantly higher post-surgical complications, in-hospital mortality (Black OR = 1.18, 95 % CI: 1.00-1.39), and longer hospital stay (Black β = 1.33, 95 % CI: 1.16-1.50) compared with White patients or patients with private insurance.

Conclusion

Racial and socio-economic differences were observed in the receipt of surgery and surgical outcomes among hospitalized patients with malignant colorectal cancer in the US.

Racial Differences in Diffusion of Intensity-Modulated Radiation Therapy for Localized Prostate Cancer

Intensity-modulated radiation therapy (IMRT), an innovative treatment option for prostate cancer, has rapidly diffused over the past decade. To inform our understanding of racial disparities in prostate cancer treatment and outcomes, this study compared diffusion of IMRT in African American (AA) and Caucasian American (CA) prostate cancer patients during the early years of IMRT diffusion using the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database. A retrospective cohort of 947 AA and 10,028 CA patients diagnosed with localized prostate cancer from 2002 through 2006, who were treated with either IMRT or non-IMRT as primary treatment within 1 year of diagnoses was constructed. Logistic regression was used to examine potential differences in diffusion of IMRT in AA and CA patients, while adjusting for socioeconomic and clinical covariates. A significantly smaller proportion of AA compared with CA patients received IMRT for localized prostate cancer (45% vs. 53%, p < .0001). Racial differences were apparent in multivariable analysis though did not achieve statistical significance, as time and factors associated with race (socioeconomic, geographic, and tumor related factors) explained the preponderance of variance in use of IMRT. Further research examining improved access to innovative cancer treatment and technologies is essential to reducing racial disparities in cancer care.

White-Black Differences in Cancer Incidence, Stage at Diagnosis, and Survival among Adults Aged 85 Years and Older in the United States

BACKGROUND

Increased life expectancy, growth of minority populations, and advances in cancer screening and treatment have resulted in an increasing number of older, racially diverse cancer survivors. Potential black/white disparities in cancer incidence, stage, and survival among the oldest old (≥85 years) were examined using data from the SEER Program of the National Cancer Institute.

METHODS

Differences in cancer incidence and stage at diagnosis were examined for cases diagnosed within the most recent 5-year period, and changes in these differences over time were examined for white and black cases aged ≥85 years. Five-year relative cancer survival rate was also examined by race.

RESULTS

Among those aged ≥85 years, black men had higher colorectal, lung and bronchus, and prostate cancer incidence rates than white men, respectively. From 1973 to 2012, lung and bronchus and female breast cancer incidence increased, while colorectal and prostate cancer incidence decreased among this population. Blacks had higher rates of unstaged cancer compared with whites. The 5-year relative survival rate for all invasive cancers combined was higher for whites than blacks. Notably, whites had more than three times the relative survival rate of lung and bronchus cancer when diagnosed at localized (35.1% vs. 11.6%) and regional (12.2% vs. 3.2%) stages than blacks, respectively.

CONCLUSIONS

White and black differences in cancer incidence, stage, and survival exist in the ≥85 population.

IMPACT

Continued efforts are needed to reduce white and black differences in cancer prevention and treatment among the ≥85 population. Cancer Epidemiol Biomarkers Prev; 25(11); 1517-23. ©2016 AACR.

Treatment of early-stage human epidermal growth factor 2-positive cancers among medicare enrollees: age and race strongly associated with non-use of trastuzumab

Adjuvant trastuzumab for human epidermal growth factor receptor-2 (HER2)-positive breast cancer is highly efficacious regardless of age. Recent data suggested that many older patients with HER2-positive disease do not receive adjuvant trastuzumab. Nevertheless, some of this 'under-treatment' may be clinically appropriate. We used Surveillance, Epidemiology and End Results (SEER)-Medicare data to identify patients aged ≥ 66 with stage ≥ Ib-III, HER2-positive breast cancer diagnosed during 2010-2011 (HER2 status available) who did not have a history of congestive heart failure. We described all systemic treatments received and sociodemographic and clinical characteristics associated with treatment patterns. Among 770 women 44.4 % did not receive trastuzumab, including 21.8 % who received endocrine therapy only, 6.3 % who received chemotherapy (±endocrine therapy) and 16.2 % who did not receive any systemic therapy. In addition to age and grade, race was strongly associated with non-use of trastuzumab (64.4 % of Non-Hispanic blacks vs. 43.6 % of whites did not receive trastuzumab, adjusted ORNon-Hispanic black vs. white = 3.14, 95 %CI = 1.38-7.17), and many patients with stage III disease did not receive trastuzumab. Further, 16.2 % of patients did not receive any systemic treatment and this occurred more frequently for black patients. Over 40 % of older patients with indication to receive adjuvant trastuzumab did not receive it and nearly 20 % of these patients did not receive any other treatment. Although treatment omission may be appropriate in some cases, we observed concerning differences in trastuzumab receipt, particularly for black women. Strategies to optimize care for older patients and to eliminate treatment disparities are urgently needed.

Racial/Ethnic and Socioeconomic Differences in Colorectal and Breast Cancer Treatment Quality: The Role of Physician-level Variations in Care

BACKGROUND

Despite a large body of research showing racial/ethnic and socioeconomic disparities in cancer treatment quality, the relative role of physician-level variations in care is unclear.

OBJECTIVE

To examine the effect of physicians on disparities in breast and colorectal cancer care.

SUBJECTS

Linked SEER Medicare data were used to identify Medicare beneficiaries diagnosed with colorectal and breast cancer during 1995-2007 and their treating physicians.

RESEARCH DESIGN

We identified treating physicians from Medicare claims data. We measured the use of NIH guideline-recommended therapies from SEER and Medicare claims data, and used logistic models to examine the relationship between race/ethnicity, socioeconomic status, and cancer quality of care. We used physician fixed effects to account for between-physician variations in treatment.

RESULTS

Minority and low socioeconomic status beneficiaries with breast and colorectal cancer were less likely to receive any recommended treatments as compared with whites. Overall, between-physician variation explained <20% of the total variation in quality of care. After accounting for between-physician differences, median household income explained 14.3%, 18.4%, and 13.2% of the variation in use of breast-conserving surgery, chemotherapy, and radiation for breast cancer, and 13.7%, 12.9%, and 12.6% of the within-physician variation in use of colorectal surgery, chemotherapy, and radiation for colorectal cancer, whereas race and ethnicity explained <2% of the within-physician variation in cancer care.

CONCLUSIONS

Between-physician variations partially explain racial disparities in cancer care. Residual within-physician disparities may be due to differences in patient-provider communication, patient preferences and treatment adherence, or unmeasured clinical severity.

Treatment of Breast Cancer in the Elderly

Despite the fact that the US population is aging and the numbers of older patients with breast cancer are increasing, many questions remain on how to optimally treat this patient population. Accrual of older cancer patients to clinical trials has been stagnant, and consequently, evidence-based recommendations are often limited by a lack of prospective data to inform decisions. Increasingly, one's functional status has been recognized as a critical factor in predicting for treatment toxicity, and tools such as the geriatric assessment will likely become a routine part of clinical practice over time. Here, adjuvant treatment considerations for older patients will be reviewed, including what is known about treatment efficacy, utilization patterns, and toxicity for older breast cancer patients. Improving enrollment of older patients onto clinical trials should be a national priority; it is only through prospective assessment that we can improve our approaches to treating our older patients with cancer.

Learning from social media: utilizing advanced data extraction techniques to understand barriers to breast cancer treatment

Past examinations of breast cancer treatment barriers have typically included registry, claims-based, and smaller survey studies. We examined treatment barriers using a novel, comprehensive, social media analysis of online, candid discussions about breast cancer. Using an innovative toolset to search postings on social networks, message boards, patient communities, and topical sites, we performed a large-scale qualitative analysis. We examined the sentiments and barriers expressed about breast cancer treatments by Internet users during 1 year (2/1/14-1/31/15). We categorized posts based on thematic patterns and examined trends in discussions by race/ethnicity (white/black/Hispanic) when this information was available. We identified 1,024,041 unique posts related to breast cancer treatment. Overall, 57 % of posts expressed negative sentiments. Using machine learning software, we assigned treatment barriers for 387,238 posts (38 %). Barriers included emotional (23 % of posts), preferences and spiritual/religious beliefs (21 %), physical (18 %), resource (15 %), healthcare perceptions (9 %), treatment processes/duration (7 %), and relationships (7 %). Black and Hispanic (vs. white) users more frequently reported barriers related to healthcare perceptions, beliefs, and pre-diagnosis/diagnosis organizational challenges and fewer emotional barriers. Using a novel analysis of diverse social media users, we observed numerous breast cancer treatment barriers that differed by race/ethnicity. Social media is a powerful tool, allowing use of real-world data for qualitative research, capitalizing on the rich discussions occurring spontaneously online. Future research should focus on how to further employ and learn from this type of social intelligence research across all medical disciplines.

A comparison of 12-gene colon cancer assay gene expression in African American and Caucasian patients with stage II colon cancer

Background

African American (AA) colon cancer patients have a worse prognosis than Caucasian (CA) colon cancer patients, however, reasons for this disparity are not well understood. To determine if tumor biology might contribute to differential prognosis, we measured recurrence risk and gene expression using the Oncotype DX® Colon Cancer Assay (12-gene assay) and compared the Recurrence Score results and gene expression profiles between AA patients and CA patients with stage II colon cancer.

Methods

We retrieved demographic, clinical, and archived tumor tissues from stage II colon cancer patients at four institutions. The 12-gene assay and mismatch repair (MMR) status were performed by Genomic Health (Redwood City, California). Student’s t-test and the Wilcoxon rank sum test were used to compare Recurrence Score data and gene expression data from AA and CA patients (SAS Enterprise Guide 5.1).

Results

Samples from 122 AA and 122 CA patients were analyzed. There were 118 women (63 AA, 55 CA) and 126 men (59 AA, 67 CA). Median age was 66 years for AA patients and 68 for CA patients. Age, gender, year of surgery, pathologic T-stage, tumor location, the number of lymph nodes examined, lymphovascular invasion, and MMR status were not significantly different between groups (p = 0.93). The mean Recurrence Score result for AA patients (27.9 ± 12.8) and CA patients (28.1 ± 11.8) was not significantly different and the proportions of patients with high Recurrence Score values (≥41) were similar between the groups (17/122 AA; 15/122 CA). None of the gene expression variables, either single genes or gene groups (cell cycle group, stromal group, BGN1, FAP, INHBA1, Ki67, MYBL2, cMYC and GADD45B), was significantly different between the racial groups. After controlling for clinical and pathologic covariates, the means and distributions of Recurrence Score results and gene expression profiles showed no statistically significant difference between patient groups.

Conclusion

The distribution of Recurrence Score results and gene expression data was similar in a cohort of AA and CA patients with stage II colon cancer and similar clinical characteristics, suggesting that tumor biology, as represented by the 12-gene assay, did not differ between patient groups.

Association of Breast Cancer Knowledge With Receipt of Guideline-Recommended Breast Cancer Treatment

PURPOSE

Knowledge about one's breast cancer characteristics is poor, but whether this knowledge affects treatment is uncertain. Among women with breast cancer, we examined whether tumor knowledge was associated with adjuvant treatment receipt.

METHODS

We surveyed a population-based sample of women in Northern California with stage 0 to III breast cancer diagnosed during 2010 to 2011 (participation rate, 68.5%). Interviews were conducted between 4 months and 3 years after diagnosis. Among 414 respondents with stage I to III disease, we examined receipt of guideline-recommended chemotherapy, radiation, and hormonal therapy by reporting correct information about one's tumor, including stage, estrogen receptor, human epidermal growth factor receptor 2 (HER2), and grade (using registry data for confirmation). We performed multivariate logistic regression to assess the probability of receiving each treatment in relevant patient groups, adjusting for patient and tumor characteristics, and examined the impact of reporting correct tumor information on treatment receipt.

RESULTS

Among relevant treatment-eligible groups, 81% received chemotherapy, 91% received radiation, and 83% received hormonal therapy. In adjusted analyses, having correct (v incorrect) information for stage and HER2 were associated with chemotherapy receipt (odds ratio [OR], 4.45; 95% CI, 1.50 to 12.50 for stage; OR, 2.70; 95% CI, 1.02 to 7.18 for HER2). Correctly reporting estrogen receptor status was associated with hormonal therapy receipt (OR, 3.91; 95% CI, 1.73 to 8.86), and correctly reporting stage was associated with radiation receipt (OR, 2.76; 95% CI, 1.03 to 7.40).

CONCLUSION

Knowledge about one's tumor characteristics was strongly associated with receipt of recommended therapies. Interventions to improve patients' knowledge and understanding of their cancers should be tested as a strategy for improving receipt of care.

Effects of Cancer Stage and Treatment Differences on Racial Disparities in Survival From Colon Cancer: A United States Population-Based Study

BACKGROUND & AIMS

We evaluated differences in treatment of black vs white patients with colon cancer and assessed their effects on survival, based on cancer stage.

METHODS

We collected data from the Surveillance, Epidemiology, and End Results-Medicare database and identified 6190 black and 61,951 white patients with colon cancer diagnosed from 1998 through 2009 and followed up through 2011. Three sets of 6190 white patients were matched sequentially, using a minimum distance strategy, to the same set of 6190 black patients based on demographic (age; sex; diagnosis year; and Surveillance, Epidemiology, and End Results registry), tumor presentation (demographic plus comorbidities, tumor stage, grade, and size), and treatment (presentation plus therapies) variables. We conducted sensitivity analyses to explore the effects of socioeconomic status in a subcohort that included 2000 randomly selected black patients. Racial differences in treatment were assessed using a logistic regression model; their effects on racial survival disparity were evaluated using the Kaplan-Meier method and the Cox proportional hazards model.

RESULTS

After patients were matched for demographic variables, the absolute 5-year difference in survival between black and white patients was 8.3% (white, 59.2% 5-y survival; blacks, 50.9% 5-y survival) (P < .0001); this value decreased significantly, to 5.0% (P < .0001), after patients were matched for tumor presentation, and decreased to 4.9% (P < .0001) when patients were matched for treatment. Differences in treatment therefore accounted for 0.1% of the 8.3% difference in survival between black and white patients. After patients were matched for tumor presentation, racial disparities were observed in almost all types of treatment; the disparities were most prominent for patients with advanced-stage cancer (stages III or IV, up to an 11.1% difference) vs early stage cancer (stages I or II, up to a 4.3% difference). After patients were matched for treatment, there was a greater reduction in disparity for black vs white patients with advanced-stage compared with early-stage cancer. In sensitivity analyses, the 5-year racial survival disparity was 7.7% after demographic match, which was less than the 8.3% observed in the complete cohort. This reduction likely was owing to the differences between the subcohort and the complete cohort in those variables that were not included in the demographic match. This value was reduced to 6.5% (P = .0001) after socioeconomic status was included in the demographic match. The difference decreased significantly to 2.8% (P = .090) after tumor presentation match, but was not reduced further after treatment match.

CONCLUSIONS

We observed significant disparities in treatment and survival of black vs white patients with colon cancer. The disparity in survival appears to have been affected more strongly by tumor presentation at diagnosis than treatment. The effects of treatment differences on disparities in survival were greater for patients with advanced-stage vs early-stage cancer.

Using big data for quality assessment in oncology

There is increasing attention in the US healthcare system on the delivery of high-quality care, an issue central to oncology. In the report 'Crossing the Quality Chasm', the Institute of Medicine identified six aims for improving healthcare quality: safe, effective, patient-centered, timely, efficient and equitable. This article describes how current big data resources can be used to assess these six dimensions, and provides examples of published studies in oncology. Strengths and limitations of current big data resources for the evaluation of quality of care are also discussed. Finally, this article outlines a vision where big data can be used not only to retrospectively assess the quality of oncologic care, but help physicians deliver high-quality care in real time.

Cigarette Smoking and Prostate Cancer Mortality in Four US States, 1999-2010

INTRODUCTION

In the United States, prostate cancer mortality rates have declined in recent decades. Cigarette smoking, a risk factor for prostate cancer death, has also declined. It is unknown whether declines in smoking prevalence produced detectable declines in prostate cancer mortality. We examined state prostate cancer mortality rates in relation to changes in cigarette smoking.

METHODS

We studied men aged 35 years or older from California, Kentucky, Maryland, and Utah. Data on state smoking prevalence were obtained from the Behavioral Risk Factor Surveillance System. Mortality rates for prostate cancer and external causes (control condition) were obtained from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research. The average annual percentage change from 1999 through 2010 was estimated using joinpoint analysis.

RESULTS

From 1999 through 2010, smoking in California declined by 3.5% per year (-4.4% to -2.5%), and prostate cancer mortality rates declined by 2.5% per year (-2.9% to -2.2%). In Kentucky, smoking declined by 3.0% per year (-4.0% to -1.9%) and prostate cancer mortality rates declined by 3.5% per year (-4.3% to -2.7%). In Maryland, smoking declined by 3.0% per year (-7.0% to 1.2%), and prostate cancer mortality rates declined by 3.5% per year (-4.1% to -3.0%).In Utah, smoking declined by 3.5% per year (-5.6% to -1.3%) and prostate cancer mortality rates declined by 2.1% per year (-3.8% to -0.4%). No corresponding patterns were observed for external causes of death.

CONCLUSION

Declines in prostate cancer mortality rates appear to parallel declines in smoking prevalence at the population level. This study suggests that declines in prostate cancer mortality rates may be a beneficial effect of reduced smoking in the population.

Disparities by Race, Age, and Sex in the Improvement of Survival for Major Cancers: Results From the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program in the United States, 1990 to 2010

IMPORTANCE

Substantial progress has been made in cancer diagnosis and treatment, resulting in a steady improvement in cancer survival. The degree of improvement by age, race, and sex remains unclear.

OBJECTIVE

To quantify the degree of survival improvement over time by age, race, and sex in the United States.

DESIGN, SETTING, AND PARTICIPANTS

Longitudinal analyses of cancer follow-up data from 1990 to 2010, from 1.02 million patients who had been diagnosed as having cancer of the colon or rectum, breast, prostate, lung, liver, pancreas, or ovary from 1990 to 2009 and who were included in 1 of 9 population-based registries of the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program.

MAIN OUTCOMES AND MEASURES

Hazard ratios (HRs) and 95% CIs for cancer-specific death were estimated for patients diagnosed as having any of these cancers during 1995 to 1999, 2000 to 2004, and 2005 to 2009, compared with those diagnosed in 1990 to 1994.

RESULTS

Significant improvements in survival were found for cancers of the colon or rectum, breast, prostate, lung, and liver. Improvements were more pronounced for younger patients. For patients aged 50 to 64 years and diagnosed from 2005 to 2009, adjusted HRs (95% CIs) were 0.57 (95% CI, 0.55-0.60), 0.48 (95% CI, 0.45-0.51), 0.61 (95% CI, 0.57-0.69), and 0.32 (95% CI, 0.30-0.36), for cancer of the colon or rectum, breast, liver, and prostate, respectively, compared with the same age groups of patients diagnosed during 1990 to 1994. However, the corresponding HRs (95% CIs) for elderly patients (those 75-85 years old) were only 0.88 (95% CI, 0.84-0.92), 0.88 (95% CI, 0.82-0.95), 0.76 (95% CI, 0.69-0.84), and 0.65 (95% CI, 0.61-0.70), for the same 4 cancer sites, respectively. A similar, although weaker, age-related period effect was observed for lung and pancreatic cancers. The adjusted HRs (95% CIs) for lung cancer were 0.75 (95% CI, 0.73-0.77) and 0.84 (95% CI, 0.81-0.86), respectively, for patients aged 50 to 64 years and 75 to 85 years diagnosed between 2005 and 2009, compared with the same age groups of patients diagnosed between 1990 and 1994 (0.73 [95% CI, 0.69-0.77] and 0.90 [95% CI, 0.85-0.95], respectively. Compared with whites or Asians, African Americans experienced greater improvement in prostate cancer survival. From 1990 to 2009, ovarian cancer survival declined among African Americans but improved among whites. No apparent sex difference in the degree of improvement for any non-sex-specific cancer was noted.

CONCLUSIONS AND RELEVANCE

Younger patients experienced greater benefit from recent oncology advances than elderly patients. African Americans experienced poorer survival than whites for all cancers, and the racial difference decreased for prostate cancer but increased for ovarian cancer. Identifying factors associated with varied improvement in cancer survival can inform future improvements in cancer care for all.

Cancer statistics, 2016

Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data were collected by the National Cancer Institute (Surveillance, Epidemiology, and End Results [SEER] Program), the Centers for Disease Control and Prevention (National Program of Cancer Registries), and the North American Association of Central Cancer Registries. Mortality data were collected by the National Center for Health Statistics. In 2016, 1,685,210 new cancer cases and 595,690 cancer deaths are projected to occur in the United States. Overall cancer incidence trends (13 oldest SEER registries) are stable in women, but declining by 3.1% per year in men (from 2009-2012), much of which is because of recent rapid declines in prostate cancer diagnoses. The cancer death rate has dropped by 23% since 1991, translating to more than 1.7 million deaths averted through 2012. Despite this progress, death rates are increasing for cancers of the liver, pancreas, and uterine corpus, and cancer is now the leading cause of death in 21 states, primarily due to exceptionally large reductions in death from heart disease. Among children and adolescents (aged birth-19 years), brain cancer has surpassed leukemia as the leading cause of cancer death because of the dramatic therapeutic advances against leukemia. Accelerating progress against cancer requires both increased national investment in cancer research and the application of existing cancer control knowledge across all segments of the population.

Differences in Colorectal Cancer Outcomes by Race and Insurance

Colorectal cancer (CRC) is the second most common cancer among African American women and the third most common cancer for African American men. The mortality rate from CRC is highest among African Americans compared to any other racial or ethnic group. Much of the disparity in mortality is likely due to diagnosis at later stages of the disease, which could result from unequal access to screening. The purpose of this study is to determine the impact of race and insurance status on CRC outcomes among CRC patients. Data were drawn from the Surveillance, Epidemiology, and End Results database. Logistic regressions models were used to examine the odds of receiving treatment after adjusting for insurance, race, and other variables. Cox proportional hazard models were used to measure the risk of CRC death after adjusting for sociodemographic and tumor characteristics when associating race and insurance with CRC-related death. Blacks were diagnosed at more advanced stages of disease than whites and had an increased risk of death from both colon and rectal cancers. Lacking insurance was associated with an increase in CRC related-deaths. Findings from this study could help profile and target patients with the greatest disparities in CRC health outcomes.

Factors associated with radiation therapy incompletion for patients with early-stage breast cancer

PURPOSE

The purpose of the study was to examine factors associated with adjuvant radiation treatment (RT) incompletion for women with breast cancer within a large national cancer database.

METHODS

We identified 394,334 women diagnosed with stage I-III breast cancer during 2004-2012 in the national cancer database who initiated adjuvant external beam adjuvant RT and examined the proportion of women not completing treatment. We used multivariable logistic regression to examine patient, clinical, and facility factors associated with RT incompletion for those who had breast-conserving surgery (BCS), defined as <15 fractions and <3990 centiGray [cGy] (accounting for adoption of hypofractionation), and mastectomy (PMRT, defined as <5000 cGy and <25 fractions), separately. We also examined RT incompletion after BCS using more traditional definitions of <25 fractions and <4500 cGy for diagnosis years ≤2010.

RESULTS

Among the 319,003 women who underwent BCS and the 75,331 women who underwent mastectomy and initiated RT, 98.4 and 97.8 % completed radiation, respectively. In adjusted analyses, older age was associated with RT incompletion (odds ratio [O.R.] for age ≥80 = 2.53 for BCS-treated, 95 % confidence interval [CI] 2.19-2.92; O.R. for PMRT incompletion = 2.33, 95 % CI 1.84-2.96; both versus age <50). In addition, those with ≥2 comorbidities and lower-risk disease had higher odds of RT incompletion. After defining RT completion using more traditional definitions, 94.0 % completed treatment.

CONCLUSIONS

Reassuringly, we found a very low proportion of patients not completing RT, though we observed a higher likelihood for treatment incompletion in some sub-groups, most notably older women. Further studies should focus on reasons for treatment discontinuation in populations at risk for suboptimal treatment.

Race and Insurance Differences in the Receipt of Adjuvant Chemotherapy Among Patients With Stage III Colon Cancer

PURPOSE

Although the incidence and mortality of colon cancer in the United States has declined over the past two decades, blacks have worse outcomes than whites. Variations in treatment may contribute to mortality differentials.

METHODS

Patients diagnosed with stage III colon cancer were randomly sampled from the SEER program from the years 1990, 1991, 1995, 2000, 2005, and 2010. Patients were categorized as non-Hispanic white (n = 835) or black (n = 384). Treatment data were obtained from a review of the medical records, and these data were verified through contact with the original treating physicians. Log-binomial regression models were used to estimate the association between race and receipt of adjuvant chemotherapy. Effect modification by insurance was assessed with use of single referent models.

RESULTS

Receipt of adjuvant chemotherapy among both white and black patients increased from the period encompassing the years 1990 and 1991 (white, 58%; black, 45%) to the year 2005 (white, 72%; black, 71%) and then decreased in the year 2010 (white, 66%; black, 57%). There were marked racial disparities in the time period of 1990 to 1991 and again in 2010, with black patients less likely to receive adjuvant chemotherapy as compared with white patients (risk ratio [RR], .82; 95% CI, .72 to .93). For black patients, receipt of adjuvant chemotherapy did not differ across insurance categories (RR for private insurance, .80; 95% CI, .69 to .93; RR for Medicare, .84; 95% CI, .69 to 1.02; and RR for Medicaid, .84; 95% CI, .69 to 1.02), although a larger proportion had Medicaid in all years of the study as compared with white patients.

CONCLUSION

The chemotherapy differential narrowed after the time period of 1990 to 1991, but our findings suggest that the disparity reemerged in 2010. Recent decreases in chemotherapy use may be due, in part, to the economic downturn and an increase in Medicaid coverage.

Understanding the Racial and Ethnic Differences in Cost and Mortality Among Advanced Stage Prostate Cancer Patients (STROBE)

The aims of the study were to understand the racial/ethnic differences in cost of care and mortality in Medicare elderly with advanced stage prostate cancer.This retrospective, observational study used SEER-Medicare data. Cohort consisted of 10,509 men aged 66 or older and diagnosed with advanced-stage prostate cancer between 2001and 2004. The cohort was followed retrospectively up to 2009. Racial/ethnic variation in cost was analyzed using 2 part-models and quantile regression. Step-wise GLM log-link and Cox regression was used to study the association between race/ethnicity and cost and mortality. Propensity score approach was used to minimize selection bias.Pattern of cost and mortality varies between racial/ethnic groups. Compared with other racial/ethnic groups, non-Hispanic white patients had higher unadjusted costs in treatment and follow-up phases. Quintile regression results indicated that in treatment phase, Hispanics had higher costs in the 95th quantile and non-Hispanic blacks had lower cost in the 95th quantile, compared with non-Hispanic white men. In terminal phase non-Hispanic blacks and Hispanics had higher cost. After controlling for treatment, all-cause and prostate cancer-specific mortality was not significant for non-Hispanic black men, compared with non-Hispanic white men. However, for Asians, mortality remained significantly lower compared with non-Hispanic white men.In conclusion, relationship between race/ethnicity, cost of care, and mortality is intricate. For non-Hispanic black men, disparity in mortality can be attributed to treatment differences. To reduce racial/ethnic disparities in prostate cancer care and outcomes, tailored policies to address underuse, overuse, and misuse of treatment and health services are necessary.

Race/ethnicity and socio-economic differences in breast cancer surgery outcomes

BACKGROUND

The purpose of this study is to evaluate racial and socio-economic differences in breast cancer surgery treatment, post-surgical complications, hospital length of stay and mortality among hospitalized breast cancer patients.

METHODS

We examined the association between race/ethnicity and socio-economic status with treatment and outcomes after surgery among 71,156 women hospitalized with a primary diagnosis of breast cancer using the Nationwide Inpatient Sample database from 2007 to 2011. Multivariable regression models were used to compute estimates, odds ratios and 95% confidence intervals adjusting for age, comorbidities, stage at diagnosis, insurance, and residential region.

RESULTS

Black women were more likely to receive breast conserving surgery but less likely to receive mastectomies compared with white women. They also experienced significantly longer hospital stays (β=0.31, 95% CI: 0.24, 0.39), post-surgical complications (OR=1.21, 95% CI: 1.04-1.42) and in-hospital mortality (OR=1.26, 95% CI: 1.07-1.50) compared with Whites, after adjusting for other factors including the number of comorbidities and treatment type.

CONCLUSION

Among patients hospitalized for breast cancer, there were racial differences observed in treatment and outcomes. Further studies are needed to fully characterize whether these differences are due to individual, provider level or hospital level factors, and to highlight areas for targeted approaches to eliminate these disparities.

Diabetes management before and after cancer diagnosis: missed opportunity

BACKGROUND

Few studies have examined the management of comorbidities in cancer patients. This study used population-based data to estimate the guideline concordance rates for diabetes management before and after cancer diagnosis and examined if diabetes management services among cancer patients was associated with characteristics of the hospital where the patient was treated.

METHODS

We linked 2005-2009 Medicare claims data to information on 2,707 breast and colorectal cancers patients in state cancer registry files. Multivariate logistic regression models examined hospital characteristics associated with receipt of diabetes management care after cancer diagnosis.

RESULTS

The rates of HbAlc testing, LDL-C testing, and retinal eye exam decreased from 72.7%, 79.6%, and 57.9% before cancer diagnosis to 58.3%, 69.5%, and 55.8% after diagnosis. The pre- and post-diagnosis diabetes management care was not significantly different by hospital characteristics in the bivariate analysis except for that the distance between residence and hospital was negatively related to retinal eye exam after diagnosis (P<0.05). The multivariate analysis did not identify any significant differences in diabetes management care after cancer diagnosis by hospital characteristics.

CONCLUSIONS

Cancer patients received fewer diabetes management care after diagnosis than prior to diagnosis, even for those who were treated in large comprehensive centers. This may reflect a missed opportunity to connect diabetic cancer patients to diabetes care. This study provides benchmarks to measure improvements in comorbidity management among cancer patients.

Racial disparities in the use of SBRT for treating early-stage lung cancer

OBJECTIVES

Prior studies have shown that the surgical resection rate for black patients with early-stage lung cancer is significantly lower than that of white patients, which may partially explain the worse outcomes observed in this group. Over the past decade, however, there has been increasing utilization of stereotactic body radiotherapy (SBRT) as an alternative to surgical resection for inoperable patients. We undertook a population-based study to evaluate potential racial disparities in the use of SBRT.

MATERIALS AND METHODS

Using the National Cancer Database, black and white patients with Stage I NSCLC between 2003 and 2011 were identified. Patients were categorized based on primary treatment modality. Univariable and multivariable analyses were performed to identify demographic predictors of SBRT utilization in the non-operative population.

RESULTS

A total of 113,312 patients met the inclusion criteria. When compared to white patients, black patients were less likely to receive surgical intervention (66% vs. 58%, P<0.001) or SBRT (6.1% vs. 5.5%, P<0.001), and more likely to receive standard fractionated external beam radiation (EBRT) or no treatment. When confined to the non-operative cohort, multivariable logistic regression confirmed black race to be negatively associated with SBRT use compared to less aggressive therapy.

CONCLUSION

In this national dataset, we confirmed prior observations that black patients are less likely to receive surgery than white patients, and also found that black patients are less likely to receive SBRT. This suggests that even with emerging utilization of SBRT for inoperable candidates, black patients continue to receive less aggressive therapy.

Black/White Disparities in Receipt of Treatment and Survival Among Men With Early-Stage Breast Cancer

PURPOSE

To examine the extent of black/white disparities in receipt of treatment and survival for early-stage breast cancer in men age 18 to 64 and ≥ 65 years.

PATIENTS AND METHODS

We identified 725 non-Hispanic black (black) and 5,247 non-Hispanic white (white) men diagnosed with early-stage breast cancer from 2004 to 2011 in the National Cancer Data Base. We used multivariable logistic regression and calculated standardized risk ratios to predict receipt of treatment and a proportional hazards model to estimate overall hazard ratios (HRs) in black versus white men age 18 to 64 and ≥ 65 years, separately.

RESULTS

Receipt of treatment was remarkably similar between blacks and whites in both age groups. Black and white older men had lower receipt of chemotherapy (39.2% and 42.0%, respectively) compared with younger patients (76.7% and 79.3%, respectively). Younger black men had a 76% higher risk of death than younger white men after adjustment for clinical factors only (HR, 1.76; 95% CI, 1.11 to 2.78), but this difference significantly diminished after subsequent adjustment for insurance and income (HR, 1.37; 95% CI, 0.83 to 2.24). In those age ≥ 65 years, the excess risk of death in blacks versus whites was nonsignificant and not affected by adjustment for covariates.

CONCLUSION

The excess risk of death in black versus white men diagnosed with early-stage breast cancer was largely confined to those age 18 to 64 years and became nonsignificant after adjustment for differences in insurance and income. These findings suggest the importance of improving access to care in reducing racial disparities in male breast cancer mortality.

Pulmonologist involvement, stage-specific treatment, and survival in adults with non-small cell lung cancer and chronic obstructive pulmonary disease

RATIONALE

Up to 80% of patients with lung cancer have comorbid chronic obstructive pulmonary disease (COPD). Many of them are poor candidates for stage-specific lung cancer treatment due to diminished lung function and poor functional status, and many forego treatment. The negative effect of COPD may be moderated by pulmonologist-guided management.

OBJECTIVES

This study examined the association between pulmonologist management and the probability of receiving the recommended stage-specific treatment modality and overall survival among patients with non-small cell lung cancer (NSCLC) with preexisting COPD.

METHODS

Early- and advanced-stage NSCLC cases diagnosed between 2002 and 2005 with a prior COPD diagnosis (3-24 months before NSCLC diagnosis) were identified in Surveillance, Epidemiology, and End Results tumor registry data linked to Medicare claims. Study outcomes included receipt of recommended stage-specific treatment (surgical resection for early-stage NSCLC and chemotherapy for advanced-stage NSCLC [advNSCLC]) and overall survival. Pulmonologist management was considered present if one or more Evaluation and Management visit claims with pulmonologist specialty were observed within 6 months after NSCLC diagnosis. Stage-specific multivariate logistic regression tested association between pulmonologist management and treatment received. Cox proportional hazard models examined the independent association between pulmonologist care and mortality. Two-stage residual inclusion instrumental variable (2SRI-IV) analyses tested and adjusted for potential confounding based on unobserved factors or measurement error.

MEASUREMENTS AND MAIN RESULTS

The cohorts included 5,488 patients with early-stage NSCLC and 6,426 patients with advNSCLC disease with preexisting COPD. Pulmonologist management was recorded for 54.9% of patients with early stage NSCLC and 35.7% of patients with advNSCLC. Of those patients with pulmonologist involvement, 58.5% of patients with early NSCLC received surgical resection, and 43.6% of patients with advNSCLC received chemotherapy. Pulmonologist management post NSCLC diagnosis was associated with increased surgical resection rates (odds ratio, 1.26; 95% confidence interval, 1.11-1.45) for early NSCLC and increased chemotherapy rates (odds ratio, 1.88; 95% confidence interval, 1.67-2.10) for advNSCLC. Pulmonologist management was also associated with reduced mortality risk for patients with early-stage NSCLC but not AdvNSCLC.

CONCLUSIONS

Pulmonologist management had a positive association with rates of stage-specific treatment in both groups and overall survival in early-stage NSCLC. These results provide preliminary support for the recently published guidelines emphasizing the role of pulmonologists in lung cancer management.